The Social Care Workforce: Where is the strategy?

There are many serious problems facing the staffing of social care, Jef Smith investigates what the Government is doing to help solve the issues.

One of the priorities in the Department of Health and Social Care’s (DHSC) Shared Delivery Plan: 2015 to 2020, published in February 2016, was to “make sure the health and care system workforce has the right skills and the right number of staff in the most appropriate settings to provide consistently safe and high-quality care”.

There are few signs, at least as far as care is concerned, of that promise being redeemed. The most recent workforce strategy appeared in 2009. It is hopelessly out of date, referring, for example, to several organisations which no longer exist; perhaps appropriately it can only be accessed through the National Archive. So where do we currently stand?

Social care’s position as very much the junior partner to health was underlined in December last year when Health Education England published what it called “a draft health and care workforce strategy for England to 2027”. Health Education England, however, has no formal responsibility for the adult social care workforce, and references to social care are both brief and short on detail. Meanwhile the DHSC, which is the responsible body, is said to be working with Skills for Care on “a consultation exercise to inform future strategies”, but little progress seems likely before the publication of the Green Paper on care for older people due this summer.

Recruitment crisis

Meanwhile, the crisis deepens. Annual turnover last year was 27.8% and vacancies as a proportion of all positions in care hover between 6% and 7%. The position is particularly bad for care workers and registered nurses, the vacancy rate for the latter having more than doubled over the last four years to 9%. The growth in demand for care arising from an ageing population is currently outstripping supply, but if the financial position were to improve — a slight hope, some might say — employers might still be hard placed to respond by upping their staff numbers.

The recruitment position is even worse for registered managers where vacancies have recently been running at over 11%. More worrying still, there is a widely perceived reluctance among care workers to apply for promotion to the position of registered manager as the pay is seen as frankly not enough to compensate for the high level of responsibility involved.

That fact should certainly not be taken as implying that wage rates for basic grade staff are anything like satisfactory. The median pay per hour for an independent sector care worker in 2016–2017 was £7.50, only slightly above the minimum wage. Whether depressed status follows poor pay or the reverse, care work is generally viewed by the public as requiring low levels of skill and offering limited career progression.

Opinion is divided on whether the large number of immigrants in the social care workforce has significantly contributed to depressing wage levels. What is certain is that successive waves of immigration, latterly of course from continental Europe, have made a very substantial contribution to keeping social care afloat. Around 7% of the care workforce and 26% of nurses working in social care settings are non-British European Economic Area (EEA) nationals, but uncertainty about their future status is already beginning to depress recruitment. From a steady build-up of nurses arriving in Britain from the EEA during the early years of this decade, the figures have dropped steeply since 2016. The precise outcomes of government policy and even the policy itself remain unclear, but it is alarming that the DHSC appears to have so little influence over an issue vital to the sector’s capacity to respond to need.

While almost everybody agrees that closer integration of health and care would be worthwhile, the argument relating to the workforces of the two sectors is much more nuanced. When Caroline Dinenage, Minister for Care, recently reported that the forthcoming Green Paper “will set out vital reforms to support the social care workforce, find a sustainable financial footing and bring health and social care closer together”, she was ignoring the fact that there is considerable tension between those objectives. Both wage levels and career prospects for care assistants, nurses and managers are markedly better in the NHS than in most residential and domiciliary care settings which, as integration progresses, will have to compete for staff even more intensively with a relatively well-resourced health service.

Pay and funding

The managers of organisations providing social care are generally of the opinion that their staff deserve more, but the amount they can allocate to pay, by far their greatest area of expenditure, is very largely dependent on the income they generate from the bodies which commission their services, predominantly local authorities. Councils for their part freely acknowledge that the fees they are paying are generally below the benchmark costs of care, but they then point out in justification that their budgets, largely dependent on central Government grants, have been heavily cut in recent years and are still falling.

Within Whitehall, the division of functions between the DHSC and the Ministry of Housing, Communities and Local Government (MHCLG), the former responsible for policy, the latter for the bulk of the funding, is a constant source of confusion. At the delivery end of the spectrum, there are more than 20,000 organisations providing services, resulting, says the National Audit Office (NAO), “in a care market that is fragmented with complex chains of commissioning, provision and accountability”. This intricate organisational web, involving elements of both competition and collaboration, leads inexorably to a failure to pin down responsibility. This is the major factor in creating such a confused lack of strategic thinking on the workforce.

Growth in numbers

Major questions hang over social care. The growth in demand, notably from an ageing population but also including the increasingly complex needs of people with physical and mental illness and disability, should logically — that is if free market conditions prevailed — result in a large scale increase in the workforce. The best estimate, made by the Centre for Workforce Intelligence in 2014, projected the demand for full-time equivalent jobs in adult social care to rise from the current number of around 1.34 million to about 2 million by 2035. Such a growth, which of course depends on all sorts of assumptions about funding, cannot be achieved without some degree of central management.

Staffing remains predominantly, and quite properly, the responsibility of employers. Working conditions, access to training opportunities, the quality of supervision, simple human relations — all of these play a role in attracting and, crucially, retaining good staff. The priorities were recently summarised by Andrea Sutcliffe, the Care Quality Commission’s Chief Inspector for Social Care, as: “first to improve the attraction of social care as a career; recruit the right staff; strengthen learning and development; and show that career progression is possible”. But all roads lead back to the absence of national, and therefore of regional and local, planning, and here the DHSC’s dereliction of duty is nothing short of scandalous.

As mentioned at the beginning of this article, one of the listed priorities in the DHSC’s document Shared Delivery Plan: 2015 to 2020, published in February 2016, was to “make sure the health and care system workforce has the right skills and the right number of staff in the most appropriate settings to provide consistently safe and high-quality care”. We are half way through that planning cycle and there is little sign that those promises are being taken seriously. The NAO has done a good job in detailing the issues. It is now up to the DHSC to take appropriate action.

What can I do about this situation?

  • Brief your Member of Parliament about the crisis in social care staffing.

  • Be ready to react to the Green Paper when it is published especially if it fails to deal realistically with workforce issues.

  • Press the DHSC through whatever channels are available to take the preparation of a social care workforce strategy more seriously.